2. Hamilton Hall MD FRCSC Julia Alleyne MD CCFP
Managing Back Pain The Ontario Initiative Introducing the CORE Back Tool
Hamilton Hall MD FRCSC
Julia Alleyne MD CCFP

3. Faculty/Presenter Disclosure
Faculty: Hamilton Hall
Relationships with commercial interests:
Consultant: Stryker Spine USA
Consultant: Medtronic
Consultant: rti Surgical
Medical Director, Pure Healthy Back
Medical Director, CBI Health Group

4. Disclosure of Commercial Support
This program has received no financial support.
This program has received no in-kind support.
Potential for conflict of interest:
Hamilton Hall receives compensation as Medical Director of CBIHG.

5. Mitigating Potential Bias
This program does not discuss or recommend commercial services or surgical devices.
Dr. Hall acknowledges that the Pattern Approach to Low Back Pain was developed during his time with CBIHG and that its development included contributions from many CBIHG staff members.

6. Faculty/Presenter Disclosure
Faculty: Dr. Julia Alleyne
Relationships with commercial interests:
Speakers Bureau/Honoraria: Lavin Agency
Excludes medical education and medical conferences.

7. Disclosure of Commercial Support
This program has received no financial support.
This program has received no in-kind support.
Potential for conflict of interest:
Dr. Julia Alleyne has received payment from Centre for Effective Practice (CEP) as the clinical lead on the Ministry of Health and Long-Term Care (MOHLTC) provincial Low Back Pain Strategy

8. Mitigating Potential Bias
This program does not discuss or recommend commercial services or surgical devices.
Dr. Alleyne acknowledges that she was the clinical lead in the development of the CORE back tool.
Payment received by Dr. Alleyne is non-commercial (received from MOHLTC)

9. #1 All Musculoskeletal Conditions
Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4–33% of the population at any given point.
Anthony Woolfe
Burden of major musculoskeletal conditions
Bulletin of the World Health Organization 2003;81:646-6

10. What do we do ?

11. Barriers to Best Practice: Patients with Low Back Pain
Family physicians perceive that they require additional knowledge and skills to deal with patient expectations, appropriate imaging and consultant referrals and patient self-management strategies.
Primary care providers cited patient pressure, both direct and indirect, as a key reasons to order tests and specialty referrals.
Knowledge gaps exist for patients as well but are often not addressed within the office visit.

12. Our current approach isn’t working
The medical paradigm hasn’t solved the problem of low back pain.
Guideline: discordant indicators
23,918 primary care visits for back pain
Jan 1999 – Dec 2010
MRI increase use 7.2% to 11.3%
Mafi J et al. JAMA 2013

13. Our current approach isn’t working

14. Our current approach isn’t working
Guideline: discordant indicators
23,918 primary care visits for back pain
Jan 1999 – Dec 2010
MRI increase use 7.2% to 11.3%
NSAID/acetaminophen decrease use 36.9% to 24.5%
Narcotic increase use 19.3% to 29.1%
Specialist referrals increase 6.8% to 14.0%
Mafi J et al. JAMA 2013

15. Our current approach isn’t working
There is no correlation between degenerative changes on plain x-ray and back pain.
CT has a 30% false positive rate.
MRI has a 60-90% false positive rate.
Early MRI without indication has a strong iatrogenic effect in acute LBP… it provides no benefits, and worse outcomes are likely.
Webster BS et al. Spine 2013

16. Our current approach isn’t working
With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.
Everything else is labeled “non-specific” back pain.

17. Our current approach isn’t working
With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.
Everything else is labeled “non-specific” back pain. It is treated “non-specifically”,

18. Our current approach isn’t working
With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.
Everything else is labeled “non-specific” back pain. It is treated “non-specifically”, which doesn’t work.

19. And our current approach is wrong
Most back pain is not the result of
tumour
infection
major trauma
or any medical problem
Most back pain begins spontaneously.
In a study of over 11,000 patients, 2/3rds of the subjects could not recall any cause for the pain.
Hall et al. Clin J Pain 1998

20. But we still memorize the Red Flags
Sphincter disturbance: bowel or bladder
History of cancer
Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

21. So why don’t we look there first?
There is another way
Over 90% of back pain is caused by minor altered mechanics.
Most back pain is mechanical.
So why don’t we look there first?

22. It means there is a sore thing in the back.
There is another way
Over 90% of back pain is caused by minor altered mechanics.
Mechanical back pain is pain
related to movement
related to position
related to a physical structure
It means there is a sore thing in the back.

23. There is another way
We can all recognize there is a sore thing. We just can’t agree on which sore thing. And for all the non-invasive treatments locating the sore thing isn’t even necessary.

24. There is another way
“Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”
Quebec Task Force 1987

25. Patterns of back pain
“Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”

26. Syndromes of back pain
“Distinct syndromes of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” What is a syndrome?

27. A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion.

28. A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion What is the difference between a disease and a syndrome?

29. The only difference is that we know the etiology of a disease.
A disease has an etiology.
Does a syndrome have an etiology?
Do you think that constellation of signs and symptoms just appears in exactly the same way every time merely by chance?
Of course, a syndrome has an etiology.
We just don’t know what it is yet.

30. Syndrome recognition The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?

31. Where is your pain the worst?
Is it back or leg dominant?
Back dominant pain is referred pain from a physical structure.
Back dominant:
back
buttocks
coccyx
greater trochanters
groin

32. Where is your pain the worst?
Is it back or leg dominant?
Back dominant pain is referred pain from a physical structure.
Sites of referred pain can become locally tender.
Trochanteric bursitis

33. Where is your pain the worst?
Is it back or leg dominant?
Leg dominant pain is radicular pain from nerve root involvement.
Leg dominant:
Around or below the gluteal fold, to the:
thigh
calf
ankle
foot

34. Where is your pain the worst?
Is it back or leg dominant?
The patient will often report both.
But it must be one or the other.
“ If I could stop only one pain, which one do I stop?
“I have a back pill and a leg pill, which one do you want?”

35. Syndrome recognition The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?
Is your pain constant or intermittent?

36. Part A
Is there ever a time when you are in your best position, in your best time of your day and everything is going well when your pain stops even for a moment? I know it comes right back but is there ever a time, even a short time when the pain is gone?

37. Part B
When your pain stops does it stop completely? Is it all gone? Are you completely without your pain?

38. When the pain is constant consider:
Malignancy
Systemic conditions
Pain disorder
Constant mechanical pain

39. Does bending forward make your typical pain worse?
Syndrome recognition
The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?

40. Does bending forward make your typical pain worse?
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
What are the aggravating movements/positions?

41. Has there been a change in your bowel or bladder function
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
Has there been a change in your bowel or bladder function
since the start of your pain?

42. Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
Has there been a change in your bowel or bladder function
since the start of your pain?
5. If you are under 45 years, do you have morning stiffness greater than 30 min?

44. What can’t you do now that you could do before you were in pain and why?

46. What are the relieving movements/ positions?
What can’t you do now that you could do before you were in pain and why?
What are the relieving movements/ positions?

47. Have you had this same pain before?
What can’t you do now that you could do before you were in pain and why?
What are the relieving movements/ positions?
Have you had this same pain before?

48. What treatment have you had? Did it work?
What can’t you do now that you could do before you were in pain and why?
What are the relieving movements/ positions?
Have you had this same pain before?
What treatment have you had? Did it work?

49. But we still memorize the Red Flags
Sphincter disturbance: bowel or bladder
History of cancer
Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

52. History takes precedence over physical examination
History takes precedence over physical examination. But the physical examination must support the history.

53. Physical Examination Observation general activity and behaviour
back specific:
contour
colour
scars
palpation (if you must)

54. Physical Examination
Observation
Movement
flexion
extension

55. Physical Examination Nerve root irritation tests straight leg raising
Observation
Movement
Nerve root irritation tests
straight leg raising

56. A positive straight leg raise:
Passive test - the examiner lifts the leg
Reproduction/exacerbation of typical leg dominant pain
Back pain is not relevant
Produced at any degree of leg elevation
To reduce confusion with hamstring tightness, flex the opposite hip and knee.

57. Physical Examination Nerve root conduction tests Observation Movement
Nerve root irritation tests
Nerve root conduction tests L4 L5 S1
knee reflex
great toe extension
great toe flexion

58. Physical Examination Upper motor test Observation Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
plantar response
clonus

59. Physical Examination Saddle sensation Observation Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
lower sacral nerve roots (2,3,4) test

60. Physical Examination Sensory testing (if indicated) Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
Sensory testing (if indicated)

61. Physical Examination Ancillary testing (if indicated) Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
Sensory testing (if indicated)
Ancillary testing (if indicated)
hip, abdomen, peripheral pulses

63. There are four mechanical patterns
Pattern 1 PEP
Pattern 1 PEN
Pattern 4 PEP
Pattern 4 PEN

64. Pattern 1
Probably discogenic

65. History Back dominant pain Worse with flexion Constant or Intermittent
Pattern 1

66. Physical Examination Back dominant pain Worse with flexion
Neurological examination is normal
or unrelated to the pattern
Pattern 1

67. The patient has a directional preference.
Physical Examination
Back dominant pain
Worse with flexion
Neurological examination is normal
Better with 5 prone passive extensions
Pattern 1 Prone Extension Positive
PEP
The patient has a directional preference.
Pattern 1

68. Physical Examination Back dominant pain Worse with flexion
Neurological examination is normal
No change/worse with 5 prone passive extensions
Pattern 1 Prone Extension Negative
PEN
The patient has no directional preference.
Pattern 1

69. Management Pattern 1 PEP – educate and exercise
Reduce sitting / flexion
Increase extension
lumbar roll
night roll
Prescribe repeated prone extensions

70. Management Pattern 1 PEN – educate and exercise
Goal oriented therapy referral
Increase gradually and progressive from unweighted flexion to extension position then prone extensions
When range improves and pain decreases add core stability
Analgesics

71. Pattern 1
Pattern 1 PEP
Pattern 1 PEN

72. Pattern 2
Have no idea

73. History Back dominant pain Worse with extension
Never worse with flexion
Always intermittent
Pattern 2

74. History Back dominant pain Worse with extension
Never worse with flexion
Always intermittent
If the pain is constant or if there is any pain
on flexion the patient is Pattern 1
Pattern 2

75. Physical Examination Back dominant pain Worse with extension
Neurological examination is normal or unrelated to the pattern
No effect or better with flexion
Pattern 2

76. Management Pattern 2 – educate and exercise
Relief with sitting / flexion
Reduce extension, frequent breaks
Prescribe sitting unweighted flexion
Posture and positioning in flexion

77. Pattern 1
Pattern 2
Pattern 1 PEP
Pattern 1 PEN

78. Certainly nerve root irritation
Pattern 3
Certainly nerve root irritation
“sciatica”

79. History Leg dominant pain Always constant
Affected by back movement/position
Pattern 3

80. Physical Examination Leg dominant pain
Leg pain affected by back movement
Positive irritative test
and/or conduction loss
Pattern 3

81. Management Pattern 3 – reassure
Scheduled rest positions during the day
Z lie
prone over pillows
Change position as pain increases
Stronger Analgesics
Refer to surgery (15%)

82. Pattern 1
Pattern 2
Pattern 3
Pattern 1 PEP
Pattern 1 PEN

83. Pattern 4
PEP

84. History Leg dominant pain Always intermittent Worse with flexion
Pattern 4 PEP

85. Leg dominant pain that responds to mechanical treatment.
Physical Examination
Rarely a positive irritative test and/or conduction loss
Always better with unloaded back extension movement or position
Leg dominant pain that responds to mechanical treatment.
Pattern 4 PEP

86. Management Pattern 4 PEP – educate and exercise
Reduce sitting / flexion
Increase extension
lumbar roll
night roll
Prescribe repeated unloaded extension positions and movements

87. Neurogenic claudication
Pattern 4
PEN
Neurogenic claudication

88. History Leg dominant pain Always intermittent
Worse with activity in extension
Better with rest in flexion
May have transient weakness
Pattern 4 PEN

89. Physical Examination Negative irritative tests
Possible permanent conduction loss
Pattern 4 PEN

90. Management Pattern 4 PEN – educate and exercise
Goal oriented therapy referral
Abdominal strengthening
Core strengthening
Posture training - pelvic tilt
Long term commitment
Gradual improvement
Excellent surgical candidates

91. Constant /Intermittent
Back dominant
Leg dominant
Constant /Intermittent
Intermittent
Constant
Intermittent
Pattern 1
Pattern 4
Pattern 2
Pattern 3
Pattern 1 PEP
Pattern 1 PEN
Pattern 4 PEP
Pattern 4 PEN

92. That’s all there is Mechanical Syndromes Unequivocal history
Anticipated
treatment response
Concordant
physical examination

93. Low Back Pain Patterns
Another option to see all of the options a little more clearly. 93

94. Start with the patterns
There will be a pattern in ninety percent of your patients.
The pattern suggests the initial treatment.
If the pain responds as expected, you have your solution.
If there is no syndrome or it doesn’t respond as anticipated, that is the group that needs to be investigated.
That is the time to consider the Red Flags.